• Nobutaka Yoshioka and Shinsuke Tominaga.
• Department of Craniofacial Surgery and Plastic Surgery, Tominaga Hospital, Osaka, Japan. Electronic address: Yoshioka0225@aol.com.
• World Neurosurg. 2018 Nov 1; 119: e734-e739.

ObjectiveTitanium mesh implants (TMIs) are used for various purposes in craniotomy. Although delayed implant exposure and thinning of the overlying skin are well-known complications, the mechanism has not yet been elucidated. We reviewed our cases and propose a mechanism for TMI exposure.MethodsFrom 2009 to 2018, we treated 14 patients with delayed titanium implant exposure after craniotomy. The exposed titanium implant was a TMI in 4 patients, a titanium mesh plate in 6 patients, and a titanium fixation plate with holes in 4 patients. We reviewed the preoperative computed tomography (CT) scans and operative findings.ResultsThe interval between craniotomy and implant exposure was 13 years (range, 5-27). Implant exposure occurred at the temporal region in 7 patients, frontal region in 6 patients, and parietal region in 1 patient. The skin ulcer size ranged from 0.25 to 10 cm2 (mean, 1.95). In the patients with TMI exposure, the dura was expanded, and no residual epidural space was identified on the CT scans; however, epidural dead space was revealed on the CT scan in the patients with titanium mesh plate or titanium fixation plate exposure.ConclusionsWe believe that the key factor resulting in delayed titanium mesh exposure is the pressure gradient between the atmosphere and the intracranial space. Fluctuation of this gradient exerts dynamic stress on the tissue in the mesh holes and the adjacent tissue, resulting in tissue damage and implant exposure.Copyright © 2018 Elsevier Inc. All rights reserved.

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